1457353674 NPI number — F ALLEN MOORHEAD JR

Table of content: (NPI 1457353674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457353674 NPI number — F ALLEN MOORHEAD JR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
F ALLEN MOORHEAD JR
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
F. ALLEN MOORHEAD JR., M.D. FAMILY PRACTICE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457353674
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
709 MAIN ST
Provider Second Line Business Mailing Address:
PO BOX 180
Provider Business Mailing Address City Name:
NEODESHA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66757-1634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-325-2200
Provider Business Mailing Address Fax Number:
620-325-2410

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
709 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEODESHA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66757-1634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-325-2200
Provider Business Practice Location Address Fax Number:
620-325-2410
Provider Enumeration Date:
06/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MOORHEAD
Authorized Official First Name:
FRANK
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
620-325-2200

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  04-13549 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , with the licence number: 178917 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100081690B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 107098 . This is a "BLUE CROSS BLUE SHIELD OF KANSAS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 1066 . This is a "BC RHC NUMBER" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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